Comparing Tenant and Neighborhood Characteristics of the VA's Project- vs. Tenant-Based Supportive Housing Program in Los Angeles County.

The United States Department of Housing and Urban Development (HUD)-Veteran Administration Supportive Housing (VASH) program uses project- and tenant-based vouchers to provide permanent supportive housing for homeless Veterans. We compared Veteran characteristics, health service utilization, and neighborhood characteristics between HUD-VASH participants with project-based (n=114) vs. tenant-based (n=978) vouchers. We found that project-based voucher holders were older and more ill than tenant-based voucher holders. Project-based vouchers were also associated with higher-quality neighborhoods and higher rates of health service utilization than tenant-based vouchers. With the limited availability of project-based vouchers, juxtaposed with the increased service use and better neighborhood quality with this voucher type, our findings suggest a need to think strategically about how best to allocate housing vouchers to meet homeless Veteran's needs.

How different is research done by the Patient-centered Outcomes Research Institute, and what difference does it make?

Aim: To determine whether research funded by the Patient-centered Outcomes Research Institute (PCORI) is consistent with the original aims of Congress and unique among other major USA funders. Methods: We compared a sample of funded projects from PCORI, NIH (Phase IV) and agency for healthcare research and quality (AHRQ; American Recovery and Reinvestment Act [ARRA]-based comparative effectiveness research funding) from 2014 to 2018 on number of outcomes/study, patient-centeredness of outcomes (those related to survival, function, symptoms and health-related quality of life) and other features that may characterize patient-centered research (e.g., whether conducted in a real-world setting) using PCORI portfolio data and ClinicalTrials.gov. Results: The mean number of outcomes in PCORI studies (≥9) appeared higher than NIH (≥3)/AHRQ (5.5); a higher percentage of outcomes/study were patient-centered: >85% PCORI versus 50% AHRQ and ≤30% NIH. The majority of PCORI studies (≥74%) were conducted in a real-world setting; this characteristic could not be identified for NIH/AHRQ studies. Conclusion: PCORI-funded studies appear to have unique aspects relative to NIH and AHRQ that are consistent with PCORI's aims of patient-centeredness.

Mortality of older construction and craft workers employed at department of energy nuclear sites: Follow-up through 2016.

BACKGROUND: To determine if construction and trades workers employed at U.S. Department of Energy (DOE) nuclear sites facilities are at significant risk for diseases associated with occupational exposures, we compared the mortality experience of participants in the Building Trades National Medical Screening Program (BTMed) to that of the US population. METHODS: The cohort includes 24,086 BTMed participants enrolled between 1998 and 2016 and 5203 deaths. Cause-specific standardized mortality ratios were calculated based on US death rates. RESULTS: Mortality was elevated for all causes, all cancers, cancers of the trachea, bronchus, and lung and lymphatic and hematopoietic system, mesothelioma, chronic obstructive pulmonary disease, asbestosis, transportation injuries, and other injuries, particularly those caused by accidental poisoning, suggesting a possible effect of the opioid epidemic. CONCLUSIONS: Apart from other injuries, mortality patterns were very similar to those reported in the past in this population. Construction workers employed at DOE sites have a significantly increased risk for occupational illnesses. Risks are associated with employment during all time periods covered including possibly after 1990. The cancer risks closely match the cancers identified for DOE compensation from radiation exposures. The high risk of lung cancer supports the value of early lung cancer detection. Continued medical surveillance is important.

Predicting history.

Can events be accurately described as historic at the time they are happening? Claims of this sort are in effect predictions about the evaluations of future historians; that is, that they will regard the events in question as significant. Here we provide empirical evidence in support of earlier philosophical arguments1 that such claims are likely to be spurious and that, conversely, many events that will one day be viewed as historic attract little attention at the time. We introduce a conceptual and methodological framework for applying machine learning prediction models to large corpora of digitized historical archives. We find that although such models can correctly identify some historically important documents, they tend to overpredict historical significance while also failing to identify many documents that will later be deemed important, where both types of error increase monotonically with the number of documents under consideration. On balance, we conclude that historical significance is extremely difficult to predict, consistent with other recent work on intrinsic limits to predictability in complex social systems2,3. However, the results also indicate the feasibility of developing 'artificial archivists' to identify potentially historic documents in very large digital corpora.

Prevalence of LD From Parental and Professional Perspectives: A Comparison of the Data From the National Survey of Children's Health and the Office of Special Education Programs' Reports to Congress.

Since the emergence of the field of learning disabilities (LD) in the late 1960s and early 1970s, controversy has surrounded issues regarding methods used for identification. The prevalence of students identified as LD increased steadily from the 1970s until the beginning of the 21st century, at which time it has decreased until at least 2011 (the most current data available from the U.S. Office of Education). In this article, I compare the prevalence rates of children aged 6 to 17 years being served in schools according to the Office of Special Education Programs with the prevalence rates as reported by parents on the National Survey of Children's Health. To date, no such comparison has been made that takes into account parents' knowledge of their children's disabilities. Results of the analyses reveal that parents report that their children have LD at a significantly higher rate than what is reported by schools of students receiving LD services. Most important, the longitudinal trend from 2001 to 2011 indicates that parents are reporting a slight increase whereas the Office of Special Education Programs is reporting a dramatic decrease in LD.

Creating a more quit-friendly national workforce? Individual layoff history and voluntary turnover.

Although Bureau of Labor Statistics data reveal that U.S. employers laid off over 30 million employees since 1994, virtually no research has addressed the behavior of layoff victims upon reemployment. In a first step, we investigate how layoffs shape voluntary turnover behavior in subsequent jobs. Utilizing a recently developed fixed effects specification of survival analysis, we find that a layoff history is positively associated with quit behavior. This effect is partially mediated by underemployment and job satisfaction in the postlayoff job. The remaining direct effect is consistent with the notion that layoffs produce a psychological spillover to postlayoff employment, which then manifests in quit behavior. We also find that layoff effects on turnover attenuate as an individual's layoffs accumulate and vary in magnitude according to the turnover "path" followed by the leaver.

Mortality of older construction and craft workers employed at department of energy (DOE) nuclear sites: follow-up through 2011.

BACKGROUND: The Building Trades National Medical Screening Program (BTMed) was established in 1996 to provide occupational medicine screening examinations for construction workers who have worked at US Department of Energy nuclear sites. Workers participating in BTMed between 1998 and 2011 were followed to determine their vital status and mortality experience through December 31, 2011. METHODS: The cohort includes 18,803 BTMed participants and 2,801 deaths. Cause-specific Standardized Mortality Ratios (SMRs) were calculated based on US death rates. RESULTS: Mortality was elevated for all causes, all cancers, cancers of the trachea, bronchus, and lung and lymphatic and hematopoietic system, mesothelioma, COPD, and asbestosis. CONCLUSIONS: Construction workers employed at DOE sites have a significantly increased risk for occupational illnesses. Risks are associated with employment during all time periods covered including after 1980. The cancer risks closely match the cancers identified for DOE compensation from radiation exposures. Continued medical surveillance is important.

Enumeration of the governmental public health workforce, 2014.

BACKGROUND: Regular assessment of the size and composition of the U.S. public health workforce has been a challenge for decades. Previous enumeration efforts estimated 450,000 public health workers in governmental and voluntary agencies in 2000, and 326,602 governmental public health workers in 2012, although differences in enumeration methodology and the definitions of public health worker between the two make comparisons problematic. PURPOSE: To estimate the size of the governmental public health workforce in 14 occupational classifications recommended for categorizing public health workers. METHODS: Six data sources were used to develop enumeration estimates: five for state and local public health workers and one for the federal public health workforce. Statistical adjustments were made to address missing data, overcounting, and duplicate counting of workers across surveys. Data were collected for 2010-2013; analyses were conducted in 2014. RESULTS: The multiple data sources yielded an estimate of 290,988 (range=231,464-341,053) public health workers in governmental agencies, 50%, 30%, and 20% of whom provide services in local, state, and federal public health settings, respectively. Administrative or clerical personnel (19%) represent the largest group of workers, followed by public health nurses (16%); environmental health workers (8%); public health managers (6%); and laboratory workers (5%). CONCLUSIONS: Using multiple data sources for public health workforce enumeration potentially improves accuracy of estimates but also adds methodologic complexity. Improvement of data sources and development of a standardized study methodology is needed for continuous monitoring of public health workforce size and composition.

Predicting temporal trends in total absenteeism rates for civil service employees of a federal public health agency.

OBJECTIVE: This study evaluates the predictability in temporal absences trends due to all causes (total absenteeism) among employees at a federal agency. The objective is to determine how leave trends vary within the year, and determine whether trends are predictable. METHODS: Ten years of absenteeism data from an attendance system were analyzed for rates of total absence. RESULTS: Trends over a 10-year period followed predictable and regular patterns during a given year that correspond to major holiday periods. Temporal trends in leave among small, medium, and large facilities compared favorably with the agency as a whole. CONCLUSIONS: Temporal trends in total absenteeism rates for an organization can be determined using its attendance system. The ability to predict employee absenteeism rates can be extremely helpful for management in optimizing business performance and ensuring that an organization meets its mission.

Epidemiology of injuries to wildland firefighters.

INTRODUCTION: Wildland fires have significant ecologic and economic impact in the United States. Despite the number of firefighters involved in controlling them, little is known about the injuries that they sustain. We hypothesized that the mechanism of injury would predict injury characteristics and severity of fire-related injuries. METHODS: We examined firefighter injuries reported to the US Department of the Interior from the years 2003 to 2007. Associations between the injury mechanism and the injury diagnosis and body part were assessed. A logistic regression model was used to evaluate the odds of disabling injury associated with mechanism of injury after controlling for demographic and temporal variables. RESULTS: A total of 1301 nonfatal injuries to wildland firefighters were reported during the 5-year period. Mechanism of injury was significantly associated with the type of injury and injured body part (P ≤ .001). The most common injury mechanism was slips/trips/falls followed by equipment/tools/machinery. Injuries from poisoning or environmental exposure were less likely to lead to severe injury than slips, trips, or falls (odds ratio, 0.45; 95% confidence interval, 0.21-0.95). Compared with injuries in the early and peak season, those in the late season had more than twice the odds of being severe (odds ratio, 2.24; 95% confidence interval, 1.23-4.10). DISCUSSION: This study contributes important knowledge for implementing evidence-based injury prevention programs, for planning emergency medical responses on fire incidents and for provoking further inquiry into occupational risk factors affecting this high-risk occupational group.

Fire characteristics associated with firefighter injury on large federal wildland fires.

PURPOSE: Wildland fires present many injury hazards to firefighters. We estimate injury rates and identify fire-related factors associated with injury. METHODS: Data from the National Interagency Fire Center from 2003 to 2007 provided the number of injuries in which the firefighter could not return to his or her job assignment, person-days worked, and fire characteristics (year, region, season, cause, fuel type, resistance to control, and structures destroyed). We assessed fire-level risk factors of having at least one reported injury using logistic regression. Negative binomial regression was used to examine incidence rate ratios associated with fire-level risk factors. RESULTS: Of 867 fires, 9.5% required the most complex management and 24.7% required the next-highest level of management. Fires most often occurred in the western United States (82.8%), during the summer (69.6%), caused by lightening (54.9%). Timber was the most frequent fuel source (40.2%). Peak incident management level, person-days of exposure, and the fire's resistance to control were significantly related to the odds of a fire having at least one reported injury. However, the most complex fires had a lower injury incidence rate than less complex fires. CONCLUSIONS: Although fire complexity and the number of firefighters were associated with the risk for at least one reported injury, the more experienced and specialized firefighting teams had lower injury incidence.

Use of oseltamivir after influenza infection is associated with reduced incidence of recurrent adverse cardiovascular outcomes among military health system beneficiaries with prior cardiovascular diseases.

BACKGROUND: Influenza infection has been associated with increased risk of adverse cardiac and cerebral vascular outcomes. Oseltamivir, a treatment for influenza, has been shown to decrease the severity of an influenza episode, but few data exist regarding its potentially protective effect against recurrent vascular outcomes among influenza patients with a history of vascular disease. METHODS AND RESULTS: Electronic healthcare service and pharmacy records for 37,482 TRICARE beneficiaries, aged 18 and older, with a coded history of cardiovascular (CV) disease and a subsequent diagnosis of influenza from October 1, 2003, through September 30, 2007, were examined. Subjects were grouped according to whether they had filled a prescription for oseltamivir within 2 days of their influenza diagnosis. The incidence of recurrent CV events within 30 days after the influenza diagnosis among oseltavmivir-treated and untreated subjects was 8.5% and 21.2%, respectively (P<0.005). Subject age was a persistent and significant contributor to the likelihood of recurrent CV outcomes. After controlling for the differences in demographics among treated and untreated cohorts using a propensity-scored logistic regression model, a statistically significant protective effect was associated with oseltamivir treatment (odds ratio, 0.417; 95% CI, 0.349 to 0.498). CONCLUSIONS: Our findings suggests that oseltamivir treatment for influenza is associated with significant decrease in the risk of recurrent CV events in subjects with a history of CV disease. These findings merit confirmation in further prospective and controlled studies. Meanwhile, in patients with CV disease, strict adherence with current practice guidelines for prevention and treatment of influenza is recommended.

Nonparametric estimation in a Markov "illness-death" process from interval censored observations with missing intermediate transition status.

In many clinical trials patients are intermittently assessed for the transition to an intermediate state, such as occurrence of a disease-related nonfatal event, and death. Estimation of the distribution of nonfatal event free survival time, that is, the time to the first occurrence of the nonfatal event or death, is the primary focus of the data analysis. The difficulty with this estimation is that the intermittent assessment of patients results in two forms of incompleteness: the times of occurrence of nonfatal events are interval censored and, when a nonfatal event does not occur by the time of the last assessment, a patient's nonfatal event status is not known from the time of the last assessment until the end of follow-up for death. We consider both forms of incompleteness within the framework of an "illness-death" model. We develop nonparametric maximum likelihood (ML) estimation in an "illness-death" model from interval-censored observations with missing status of intermediate transition. We show that the ML estimators are self-consistent and propose an algorithm for obtaining them. This work thus provides new methodology for the analysis of incomplete data that arise from clinical trials. We apply this methodology to the data from a recently reported cancer clinical trial (Bonner et al., 2006, New England Journal of Medicine354, 567-578) and compare our estimation results with those obtained using a Food and Drug Administration recommended convention.

Influence of race on kidney transplantation in the Department of Defense healthcare system.

BACKGROUND: We report the influence of race on transplant outcomes in the Department of Defense (DOD) system. METHODS: Retrospective cohort analysis of all kidney transplants performed at WRAMC from 1996 to 2005. Kaplan-Meier analysis was used to assess for differences in graft survival, and Cox regression was used to calculate adjusted hazard ratios for graft loss. For our analyses, we used the cutoff of 6 years (year 2000) when we introduced thymoglobulin induction; maintenance immunosuppression consisted of mycophenolate mofetil and tacrolimus, and rapid steroid taper (completed withdrawal at 6 weeks) was used for all patients. RESULTS: There were 220 transplants (91 Blacks, 107 Caucasians and 22 Asians). Because the curve for graft survival for Blacks over time violated the proportional hazards assumption (at 6 years post-transplant), analysis was segregated into two segments. Through 6 years of follow-up, graft survival was 77% for Blacks and 81% for non-Blacks (p = 0.74 by log rank). Through 9 potential years of follow-up, graft survival for Blacks was 56% and 78% for Whites (p = 0.005). In Cox regression analysis, Black race, compared with non-Black race, was not significantly associated with graft loss at 6 years, but was significantly associated with graft loss occurring after 6 years. CONCLUSIONS: In the DOD health system, no significant differences were seen in graft survival among recipients of different races at 6 years. Black recipients who received a kidney transplant before the year 2000 showed decreased graft survival compared to non-Blacks. This was consistent with change in immunosuppressive regimen in our institution with the introduction of thymoglobulin induction and maintenance therapy with tacrolimus, mycophenolate mofetil and withdrawal of prednisone at 6 weeks.

Drivers of hiring discrimination for individuals with disabilities.

INTRODUCTION: Hiring discrimination in the workplace is defined as failure or refusal by an employer to engage a qualified applicant as an employee due to the existence or consequence of disability. The specific intent of this study is to determine what differentiates an allegation (perception of discrimination) from an actual discriminatory event (Merit Resolution). METHODS: Researchers used a data-mining approach, the Chi-square Automatic Interaction Detector (CHAID), to examine 19,527 resolved allegations of hiring discrimination in order to differentiate between Merit Resolution and Non-Merit Resolution outcomes. RESULTS: CHAID analysis confirmed that hiring discrimination is a complex matter with a variety of influences. Primary among these is the age of the Charging Party, with younger applicants (16-34) prevailing in their allegations 34% of the time. Within this subgroup, the sequence of predictor variables involves the Charging Party's impairment, followed by the Employer's industry classification. Behavioral disabilities, even among the young, result in generally lower Merit Resolution rates in hiring discrimination. CONCLUSIONS: Providers of training and technical assistance regarding hiring and disability may be able to adjust their services accordingly on the basis of findings such as these.

A comparison of EEOC closures involving hiring versus other prevalent discrimination issues under the Americans with Disabilities Act.

INTRODUCTION: This article describes findings from a causal comparative study of the Merit Resolution rate for allegations of Hiring discrimination that were filed with the U.S. Equal Employment Opportunity Commission (EEOC) under Title I of the Americans with Disabilities Act (ADA) between 1992 and 2005. An allegation is the Charging Party's perception of discrimination, but a Merit Resolution is one in which the EEOC has determined that a discriminatory event did indeed occur. A Non-Merit Resolution is an allegation that is closed due to a technicality or lacks sufficient evidence to conclude that discrimination occurred. Merit favors the Charging Party; Non-Merit favors the Employer. METHODS: The Merit Resolution rate of 19,527 closed Hiring allegations is compared and contrasted to that of 259,680 allegations aggregated from six other prevalent forms of discrimination including Discharge and Constructive Discharge, Reasonable Accommodation, Disability Harassment and Intimidation, and Terms and Conditions of Employment. Tests of Proportion distributed as chi-square are used to form comparisons along a variety of subcategories of Merit and Non-Merit outcomes. RESULTS: The overall Merit Resolution rate for Hiring is 26% compared to Non-Hiring at 20.6%. Employers are less likely to settle claims of hiring discrimination without mediation, and less likely to accept the remedies recommended by the EEOC when hiring discrimination has been determined. CONCLUSION: Hiring is not an unusual discrimination issue in that the overwhelming majority of allegations are still closed in favor of the Employer. However, it is counterintuitive that hiring has a higher merit resolution rate than other prevalent issues. This finding contradicts the assumption that hiring is an "invisible process." Considering that the EEOC makes merit determinations at a competitive rate, it is clear that hiring is sufficiently transparent.

Hiring discrimination against people with disabilities under the ADA: characteristics of charging parties.

INTRODUCTION: This article describes findings from a causal comparative study of the characteristics of Charging Parties who filed allegations of Hiring discrimination with the U.S. Equal Employment Opportunity Commission (EEOC) under Title I of the Americans with Disabilities Act (ADA) between 1992 and 2005. METHODS: Charging Party Characteristics derived from 19,527 closed Hiring allegations are compared and contrasted to 259,680 closed allegations aggregated from six other prevalent forms of discrimination including Discharge and Constructive Discharge, Reasonable Accommodation, Disability Harassment and Intimidation, and Terms and Conditions of Employment. Tests of Proportion distributed as chi-square are used to form comparisons along a variety of factors including age, gender, impairment, and ethnicity. RESULTS: Most allegations of ADA job discrimination fall into the realm of job retention and career advancement as opposed to job acquisition. Hiring allegations, however, tend to be filed by Charging Parties who are disproportionately male, younger or older applicants, white, and coping with physical or sensory disabilities. CONCLUSION: Prevailing theories about stigma suggest that negative attitudes are more prevalent toward persons with behavioral disabilities. However, this study provides clear evidence that one behavioral manifestation of negative attitudes, Hiring discrimination, is more often directed at persons with physical or sensory impairments. More outreach regarding ADA rights appears indicated for individuals who share the aforementioned characteristics.

Factors associated with choice of pharmacy setting among DoD health care beneficiaries aged 65 years or older.

BACKGROUND: Department of Defense (DoD) health care planners want to stimulate a voluntary migration of prescription fills from military and community pharmacies to its mail-order pharmacy, a lower-cost dispensing option for the department. Beneficiary cost share for a 90-day supply of generic/ brand medication is $0/$0 at military (DoD) pharmacies, $3/$9 at the DoD mail-order pharmacy, and $9/$27 at network community pharmacies. OBJECTIVE: To examine the pharmacy use patterns among the beneficiary population age 65 years or older, traditionally the heaviest users of the TRICARE DOD prescription drug benefit, to identify factors that are associated with beneficiary use of pharmacy setting(s). METHODS: Outpatient prescription fill records were examined for TRICARE beneficiaries age 65 years or older (N = 300,084) residing in North Carolina, Texas, and California for dates of service from December 1, 2004 through February 28, 2005. Binary logistic regression models were run for each type (military, community, and mail order) and number of pharmacy settings used by beneficiary gender, age group, catchment area status (located either within or outside a 40-mile radius of each military pharmacy), state, and number of medications obtained (defined as count of unique combinations of strength, and route of administration). The mean number of medications per beneficiary and cost per medication were tabulated for each type and number of settings used. RESULTS: In the 3-month period from December 1, 2004 through February 28, 2005, beneficiary use of military, community, and mail-order pharmacies was 45.4%, 67.6%, and 22.1%, respectively. About 67% of the study population used 1 setting exclusively and 2.4% used all 3 settings. Noncatchment residents were significantly less likely (adjusted odds ratio [AOR]= 0.080; 95% confidence interval [CI], 0.078-0.082) to use a military pharmacy exclusively and significantly more likely to use a community pharmacy (AOR = 4.64; 95% CI, 4.55-4.73) or the mail-order pharmacy (AOR = 3.92; 95% CI, 3.80-4.05) exclusively than were catchment residents. Beneficiaries taking 10 or more medications were more likely (AOR = 8.43; 95% CI, 8.21-8.65) to use multiple settings than were those who obtained 3 or fewer medications. Single-setting users obtained a median of 4 (interquartile range [IQ]) 2-7) medications with a median copayment of $7.00 (IQ $0-$13.19) per medication. Those who used all 3 settings obtained a median of 9 (IQ 7-12) medications with a median copayment of $4.33 (IQ $3.00-$6.00) per medication. Among beneficiaries who obtained 6 or more unique medications during the 90-day study period, approximately 25% used the mail-order pharmacy to obtain 1 or more prescription fills. CONCLUSION: A significant portion of the study population did not use the mail-order pharmacy despite the financial incentive to use mail-order rather than community pharmacies. Relatively small financial incentives alone may be inadequate for promoting a switch to the mail-order option among those beneficiaries not already using it in a pharmacy benefit plan with low copayments. Larger monetary and other incentives may be necessary to achieve the desired transfer of prescriptions fills to the mail-order pharmacy and the associated reduction in military pharmacy workload.